Positive lab evidence for EBV in our patient is as follows :EBV
capsid Antigen –IgM was 152 units/mL(normal <40) and IgG -109 units/mL(normal<20) were positive (CLIA quantitative method) indicating acute primary Epstein-barr virus infection.. We performed serologic tests and magnetic resonance to exclude other viral or bacterial infection, autoimmune disorder and cholangio-pancreatography to exclude structural problems. Review after two weeks was normal. One month later she presented with with acute pancreatitis & serum amylase and lipase were-457units/mL and 398units/mL respectively. There was no hepato-splenomegaly. She was managed conservatively. She became asymptomatic in 4 days, serum amylase and lipase returned to normal. . On follow-up after eight weeks child was normal. Discussion Infection-induced acute hepatitis complicated with acute pancreatitis is associated with hepatitis A virus, hepatitis B virus or hepatitis E virus. Although rare, Epstein-Barr virus (EBV) infection should be considered also in the differential diagnosis if the patient has acute hepatitis combined with pancreatitis more so if they have features of infectious mononucleosis. Ka-Hyun Yoon and Jin-Bok Hwang reported acute pancreatitis in a 11-year-old girl without any clinical symptoms of infectious mononucleosis. It was confirmed by viral capsid antigen (VCA) IgM, VCA IgG, Epstein-Barr nuclear antigen and heterophile antibody test. (1).Our case also has similar presentation. Pankaj jain ,et al reviewed 124 men with acute viral hepatitis, out of which 7 patients were found to have acute pancreatitis(5.65%). The cause of pancreatitis was hepatitis A virus in 2 patients, hepatitis E virus in 4 patients, and hepatitis B virus in 1 patient.(2)The pancreatitis was mild and all had uneventful recovery from both pancreatitis and hepatitis. Lisa Kottanattu, et al have reported simultaneously seen acute pancreatitis in 14 and acalculous cholecystitis in 37 patients with primary acute symptomatic Epstein-Barr virus infection. (3). Hassib Narchi, et al reported hepatitisin a 8 year old boy with acute pancreatitis.EBV infection was confirmed by elevatedS lipase of 1,000 IU/L (normal 30-210. alanine aminotransferase 182 IU/L aspartate aminotransferase 163 IU/L (normal 8- 20) and alkaline phosphatase 250 IU/L (normal 250-750 IU/L).) IgM for EBV viral capsid antigen (EBV VCA) was positive confirming acute primary EBV infection. (4) Concurrent acute hepatitis and acute pancreatitis in a 25 year old male was documented by Jered Cook, et al who came with 2-day history of abdominal pain, nausea and dark stools. EBV IgM antibody to the viral capsid antigen and Epstein-Barr nuclear antigen was positive. (5) Pancreatitis in a 35-year-old woman with a 6-day history of fever and sore throat., vomiting, upper abdominal pain and tenderness in epigastrium, and a macular rash across the upper trunk was reported by Zen Zhu, et al. Serum amylase level of 1300 U/L and lipase level of 1450 U/L .16%"atypical" lymphocytes on the blood film and, positive viral capsid antigen immunoglobulin M, negative viral capsid antigen immunoglobulin G (IgG), and EBV nuclear antigen IgG revealed EBV associated pancreatitis.(6)Go to:.Pancreatitis was even diagnosed after 3 weeks in a dengue patient by Rajesh, et al (7) . Conclusion . In a case of severe epigastric tenderness with hepatitis, one must also consider a possibility of EBV induced Acute Pancreatitis. . Primary acute pancreatitis due to Epstein-Barr virus infection is usually mild, and recovers fully. Recurrent pancreatitis is also a possibility.